Insurance companies in Mexico incur civil liability if they refuse to pay a policy contracted for the coverage of medical expenses, for which reason it is appropriate to claim compensation for moral damages and punitive damages, determined by the First Chamber of the Supreme Court of Justice of the Nation (SCJN) in an important precedent that will be mandatory for similar cases.
Unanimously, the five ministers that make up the First Chamber of the country’s highest court condemned an insurer to compensate a woman who suffered from cancer, since the firm that issued the policy refused to cover said disease.
The insurer did not pay the woman’s medical treatment expenses on the grounds that cervical cancer was excluded from her insurance coverage, despite the fact that the same policy mentioned, as an additional benefit, heart attack coverage and cancer in women.
Because this case had not been addressed from a gender perspective in the first jurisdictional instances to which the victim appealed, the First Chamber of the Court accepted the analysis of a Direct Amparo under Review promoted by the woman, who was given the reason.
The Chamber considered that the patient’s right to fair compensation had been violated, because the action of the insurer -by refusing to comply with its obligations and pay the insurance- allows us to presume that it is responsible for non-material damage, is established in the sentence.
When proving this type of damage to the detriment of the plaintiff, based on an analysis with a gender perspective on the situation of vulnerability in which the woman found herself, the ministers of the Court ordered the payment of compensation by the insurer . To this is added the payment of the policy, for the expenses incurred for the cancer treatment of the insured.
Similarly, the First Chamber acquitted the victim of paying legal costs as required by the company, that is, the woman will not have to pay the expenses incurred by the firm to defend herself in court, after the patient sued the consortium before the refusal to pay medical coverage.
irregular performance
The action of the insurer was considered by the Court as a repeated irregularity, while the company also incurred in an “unnecessary intrusion” to the privacy of the woman, because it asked her to carry out studies to corroborate the disease.
These analyzes were reviewed not only by the insurance company’s staff but also by people outside the insurance company, specifically, by the members of a law firm hired by the insurer, unnecessarily displaying the plaintiff’s privacy.
With all this, the First Chamber of the Court determined that the moral damage and the civil liability of the insurer are configured, for which reason the firm will have to pay compensation to the affected party.
The Chamber added that it is the duty of all judges and magistrates of the Federal Judiciary to verify that insurers have complied with their obligation to Provide information regarding insured coverage to its clients.
In the analysis of matters where breach of insurance contracts and the generation of moral and punitive damages are claimed, insurers must prove that they provided information in a complete, clear, simple and transparent manner to the insurance contracting party.
Similarly, the ministers of the First Chamber issued various guidelines for similar cases, which will be mandatory for judges and magistrates throughout the country. Among these are considering, as elements to condemn punitive damages, “bad faith and negligence that the insurance company may incur” against the claim of the person who acquired a policy.
The draft of this judgment was prepared by the minister Margarita Rios Farjat, who was unanimously supported by the other four ministers that make up the First Chamber of the Court.
Since 2011, with the judicial reform that modified article 94 of the Constitution and various numerals of the Amparo Law, it was established that They are mandatory precedents for all jurisdictional authorities of the federation and of the entities of the country, the reasons that justify the sentences dictated by the Plenary of the SCJN by a majority of eight votes, and those that are issued by the Chambers of the Court by a majority of four votes.
In this case in which the woman plaintiff was found to be right and an insurance company was sentenced, the judgment of the First Chamber was issued with the vote of the five ministers that make up this instance.
In November 2022, the same First Chamber of the Court denied an injunction to a citizen who had sued an insurance company for breach of contract. The ministers considered that the insurance companies do not violate the Constitution or the human rights of the insured, in the event that the contract is canceled due to the omission of “necessary important facts”, which must be provided by the contracting party.
Thus, omissions of information, lies or inaccurate statements given to insurance companies when insurance is contracted, they result in its complete cancellation without implying any responsibility for the consortium, while the consortium itself is responsible if it refuses to pay a policy on the grounds that a disease was not contemplated in the insurance policy. contract, as happened in the case of the woman who already obtained a sentence in her favor.
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surya palaces Journalist and lawyer, specialist in legal analysis and human rights. She has been a reporter, radio host and editor.